PLACES IN PERIL - Official Nomination Form

1.  Name and location of the site or structure: ________________________________________________________
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2.  Your name, organization or affiliation, address and phone number ______________________________________
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3.  Site Information

a.  Describe the site or structure, including its current condition, use, setting and existing zoning or protective regulations. ______________________________________________________________
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b.  What is the historical significance of the site?  Is it on the National or State Register of Historical Places? _________________________________________________________________________
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c.  Describe the impending threat ______________________________________________________
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d.  Who is involved in saving the site or structure? _________________________________________
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e.  Is ownership of this site or structure:     private    or     public?     (please circle one)

f.  Owner's Name___________________________________________________________________

     Does the owner support this nomination?     yes    or     no      (please circle one)

g.  What specific action would protect this site (ie:  purchase, rehabilitation, feasibility study, adaptive use, better zoning, heritage tourism, etc.)? _______________________________________________
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Signature                                                                                   Date

Deadline is Fall 2007
Please provide pictures which will be returned if requested.  Use additional sheets if necessary. 
Mail to:  Preserve South Dakota, 351 4th Street, Scotland, SD  57059